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First Supervised Inhalation Site Opens in North America

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First Supervised Inhalation Site Opens in North America

It's not just about allowing someone to use drugs more safely—it’s about building a trusting relationship with users, humanizing them and encouraging them to seek treatment when they’re ready.

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Inhalation rooms at ARCHES
Stacey Bourque

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In response to the opioid crisis, Canada has been rapidly opening supervised injection sites, safe spaces allowing for injection drug users to consume narcotics like heroin under medical supervision.

But ARCHES, a recently opened facility in Lethbridge, Alberta, Canada comes with a twist—it's the first supervised inhalation site in North America, allowing drug users to combust and inhale narcotics, such as meth or crack cocaine, under the supervision of trained medical staff.

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On the surface, supervised consumption sites (SCS) sound more harmful than helpful: we're letting people use dangerous, addictive drugs? What the…?

But these sites have existed around the globe for at least three decades, with more than 100 facilities in more than 66 cities. The research on them shows that they greatly reduce the spread of disease such as HIV and hepatitis C, prevent fatal overdose and connect drug users with addiction treatment and health services. Many link people with job training, counseling or housing services.

In other words, consumption sites are an important harm reduction strategy in the fight against the overdose crisis. Bottom line: they save lives.

Injection cubicles at ARCHES (photo credit: Stacey Bourque)

There’s been a major push for supervised consumption in the United States, from Philadelphia to Denver to San Francisco, but so far, these initiatives have all but stagnated. One or two may launch this summer, but the Trump Administration has threatened any that open with legal action.

Meanwhile, in Canada, consumption sites are opening at a staggering rate—at least 17 are fully operational plus around a dozen more with pending applications. The earliest SCS is Insite in Vancouver, which opened in 2003. They’ve monitored more than 3.6 million clients as they’ve injected drugs, never once experiencing a death. In fact, to the best of anyone’s knowledge, there’s never been a death at any supervised consumption site.

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But ARCHES, which opened on February 28th, is the first site in North America to offer all four modes of drug ingestion: oral, nasal, injection and inhalation. To understand why this distinction is significant, it’s important to keep the overdose crisis in context.

It’s actually polydrug use, not opioids, that are causing the most fatalities. Whether it’s due to heroin contaminated with fentanyl or mixing stimulants with depressants—known as “speedballing”—a one-strategy-fits-all approach won’t help every type of drug user.

“People are dying from all modes of consumption. It’s not the method that’s killing them, it’s the drug,” Stacey Bourque, ARCHES’ Executive Director, says in a phone call. “How come they shouldn’t have a safe place to have medical supervision when they’re just using it in a different method? And in a method that we would probably promote over injection, because there are less other unintended health consequences of use with smoking than there is with injection.”

That isn’t to say smoking drugs is entirely safe—there are still many risks, especially when drug users are in a hurry. A 2006 study published in BMC Public Health found rushed crack cocaine users had a higher prevalence of burns and inhaled metallic crack pipe filter screens. A decade later, a paper published in the same journal with a few of the same authors illustrated these potential risks are easily mediated by supervised consumption.

According to Bourque, methamphetamine injection is more prevalent in her community than opioid injection. “So if we have the opportunity to move people from injecting to inhalation, then that’s another opportunity for us to reduce harm,” she says. “Which is the purpose of our existence.”

Supervised inhalation sites are not uncommon in Europe, where they exist in The Netherlands, Switzerland, Spain, Denmark and elsewhere. Some just provide an outdoor area for smoking, while others, like ARCHES, provide sealed rooms with high-tech ventilation systems.

To meet Alberta Health’s regulations, the consumption rooms at ARCHES are negative pressure rooms so when the doors open, nothing escapes, Bourque explains. The mechanical systems are specially engineered to turn the air over 15 times an hour inside the two inhalation rooms, compared to the six times an hour it changes over in the six injection spaces.

Then there’s the built-in emergency switch that nurses, police or EMS can flip in case they need to enter the room. It immediately closes the damper and dumps the air so it becomes breathable. Finally, there’s an uninterruptible power supply system, just in case of a power failure. The ventilation system for the whole building cost about $50,000 Canadian.

In other words, these inhalation rooms aren’t outfitted with the kind of cooking exhaust fans you’ll find in your kitchen.

“I sat down with a mechanical engineer and described to him what I thought we need in a site like this to be able to keep everybody safe,” Bourque says. “We’re never actually without ventilation, so we’re not putting anyone at risk at any point.”

Another aspect of the overdose crisis is that while opioids get the most attention in mainstream media, methamphetamine and stimulant use are rising in the shadows. In Oregon, twice the number of overdose deaths are attributed to meth compared to heroin. It’s just as prevalent in places such as New Hampshire, Montana, Oklahoma and South Dakota.

Canada is no different. Meth use has been described as a “tidal wave” in Winnipeg, while in Alberta, the amount of young people seeking treatment for meth use has doubled since 2012. In Saskatchewan, the number of people admitted to drug treatment programs for meth rose 200 percent between 2015 and 2016. Fentanyl seizures in Canada have experienced a drop while meth seizures jumped approximately 100 percent in two years.

So why aren’t inhalation sites more popular? Dr. Taeko Frost, western regional director at the Harm Reduction Coalition, believes supervised injection is more palatable for the public than inhalation because the emphasis is on disease containment and keeping needles off the streets, rather than safer consumption.

“People get really stuck—pun not intended—on the syringe issue,” she says. “What this movement is really about is restoring dignity and respect and creating space for people that doesn't exist because of our housing crisis, because of policing practices, because of our failed war on drugs and drug policy.”

Frost also emphasizes the racial justice aspect of this situation.

“Depending on where you are, there may be differences between populations of people who use stimulants and people who inject drugs that may also unintentionally cut out and further perpetuate health disparities among people of color,” Frost says. “We need to be really adamant about and support safe consumption services for that reason, so that we are not further creating health disparities and discrimination by type of drug and route of administration.”

Insite has been trying to offer inhalation services for years, but the process hasn’t been easy. In order to protect staff and other clients, there would need to be costly renovations and there is no timeline for this to occur.

“Like most municipalities, Vancouver must abide by regulations protecting workers and others from secondhand smoke and there is no quick fix to this,” Carrie Stefanson, Insite’s public affairs leader, said in an email. But she doesn’t believe the route of administration has much to do with their policies—they do allow snorting drugs, for example. “Our health policies are guided by science, not public sentiment,” she says.

If something does go wrong at a SCS, there are trained medical staff on hand to immediately assist a drug user who has overdosed. In the case of an opioid overdose, breathing becomes so slow that the person suffocates. They can be revived using naloxone (Narcan), an opioid receptor antagonist that “kicks” drugs like heroin out of the brain, allowing normal breathing to resume. But for stimulants like crack cocaine and meth, there is no such antidote.

“Unfortunately, there is no silver bullet for stimulant overdoses (frequently called ‘overamping’) like in the case of opioids and naloxone,” explains Kat Humphries, the programs director at the Harm Reduction Action Center in Colorado. “But there are plenty of things you can do to help someone overamping.”

Humphries says if someone is overheating from stimulants, you should encourage them to stay still and avoid any agitated or overly-pronounced movement. Then help them cool down with ice packs, misting or fanning techniques and give them water or a drink with electrolytes. You can also place cool, wet cloths under the armpits, on back of knees, or on the forehead.

“Other signs and symptoms vary depending on the cause. You may witness anything from dehydration to hyperthermia to a severe heat stroke or heart attack,” Humphries explains. “In many cases, the person may become confused and potentially hostile, and may present as intoxicated. As the person’s heart attempts to push enough oxygen out to their whole body, their heart rate and breathing will increase. It’s important to call 911 when you feel uncomfortable managing a stimulant overdose, because it can turn deadly quickly.”

Supervised consumption sites aren’t just about allowing someone to use drugs more safely—it’s about building a trusting relationship with users, humanizing them and encouraging them to seek treatment when they’re ready. But many critics of these types of programs label it “enabling.”

“The only thing we enable is breathing,” Bourque says. “I’ve heard a lot of the healthcare professionals say, ‘We’re supposed to preserve health, we’re not supposed to help them or make it worse.’ But at the end of the day, this is healthcare. Rarely do we have somebody come in just for drug use. They always see the nurse or the counselor or the housing team. It’s never just one thing. But in order for them to access those services, you have to have a relationship built. Calling it ‘enabling someone’ is just such garbage. You can’t enable something that’s already happening.”

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